‘India needs to monitor mortality disaggregated by social groups to understand health disparities’

Discrimination and social exclusion has impacted health disparities in India’s disadvatageous groups, with Adivasis, Dalits and Muslims having a lower life expectancy than higher caste Hindus, a new study showed.

Life expectancy of Adivasis is over four years lower than that of forward-caste Hindus; that of Dalits’ is more than three years lower; and that of Muslims it’s almost a year lower, according to the paper published in the Proceedings of the National Academy of Sciences March 2022. 

The socio-economic situation explains about half the gap, but the difference in life expectancy between higher-caste Hindus and Adivasis and Dalits is comparable to the Black-White gap in the US in terms of absolute figures, the study found. 

“At 450 million, the total population of these three marginalised groups is greater than the entire population of the United States,” the analysts wrote.

Sangita Vyas, the lead author of the report titled ‘Social disadvantage, economic inequality, and life expectancy in nine Indian states’, spoke with Down To Earth about what triggered the research and what the implications of the findings are. Edited excerpts: 

Taran Deol (TD): What prompted you to take up the study? 

Sangita Vyas (SV): There hasn't been a whole lot of research that uses data to directly estimate mortality rates for these different social groups. The reason for that is because there hasn't really been great data that links socio-economic status and social groups with mortality. 

My co-authors and I decided to take this up mainly because it's an underexplored topic in India. There's been research that documents health disparities between these marginalised groups and higher-caste Hindus. So, we hypothesised that mortality for Adivasis, Dalits and Muslims would be higher than for higher-caste Hindus. The rationale behind this study was to sort of shed light on how marginalisation leads to differences in mortality. 

TD: Economic status accounted for half of the gaps in life expectancy between higher-cast Hindus and Dalits, Muslims and the Adivasis. What could be responsible for the other half?

SV: It's an open question. I think there needs to be more research on this. There needs to be data that links social groups to different behaviours and risk factors to mortality, and there's sort of an absence of large data sets that does that. 

I think that part of it may have to do with differences in the exposures that arise because of differences in the occupations. Dalits, for instance, are more likely to do sanitation work — a result of casteism in India — and that exposes them to disease, which can have impacts on their health. Therefore, the likelihood of dying. Such factors may have something to do with the part that we're not able to explain in our study.

TD:  Social disadvantage and health are closely linked. Can you elaborate on this, and why its understanding in low and middle income countries remains sparse?

SV: Part of the reason why there's so little understanding of the link between social disadvantage and health in low- and middle-income countries is because of the lack of data that link all of the things that are required to study this together. 

India doesn't have a universal vital registration system. And even in the vital registration system it does have, social groups are not always recorded on death certificates. That's the case in many low- and middle-income countries. It's really an absence of data that has contributed to a lack of understanding here. There’s also a lack of commitment on the part of governments to monitor these things. 

TD: You have drawn a parallel between what is happening in India with what is happening in the US on racial lines. Can you elaborate on the similarities?

SV:  The gaps in life expectancy between the marginalised groups and higher-caste Hindus that we find are similar and absolute in magnitude. In terms of years, they're similar to the gaps that we find between black and white Americans in US. However, India has an overall lower life expectancy compared to the US — it’s about four-fifths of it. 

Since we're starting from an overall lower level, the differences between the marginalised groups and higher-caste Hindus is actually larger in percentage terms compared to the gaps between black and white Americans in the US. 

Research has found that differences in the socio-economic status can account for about 80 per cent of the gap between black and white Americans. We were only able to account for a maximum of half of the gap between Dalits, Muslims, Adivasis and higher-caste Hindus. This needs exploring. 

TD: From a policy perspective, what can be done to address health inequalities based on indigenous identity, caste and religion?

SV: A good start would be to closely monitor mortality that's disaggregated by social groups. High-income countries like the US have governmental agencies and data-monitoring systems of differences in health and mortality by race. Such efforts are missing in India and if implemented, other things would organically arise to try to ameliorate these gaps. There are lots of potential solutions but the first important step would be to start monitoring.